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d’Entremont MA, Wee CC, Nguyen M, Couture ÉL, Lemaire-Paquette S, Kouz S, Afilalo M, Rinfret S, Schampaert E, Mansour S, Montigny M, Eisenberg M, Lauzon C, Déry JP, L’Allier P, Tardif JC, Huynh T. Racial Disparities in Acute Coronary Syndrome Management Within a Universal Healthcare Context: Insights From the AMI-OPTIMA Trial. CJC Open 2021; 3:S28-S35. [PMID: 34993431 PMCID: PMC8712605 DOI: 10.1016/j.cjco.2021.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/07/2021] [Indexed: 11/30/2022] Open
Abstract
Background Although prior studies have demonstrated racial disparities regarding acute coronary syndrome (ACS) care within private or mixed healthcare systems, few researchers have explored such disparities within universal healthcare systems. We aimed to evaluate the quality and outcomes of in-hospital ACS management for White patients vs patients of colour, within a universal healthcare context. Methods We performed a post hoc analysis of the Acute Myocardial Infarction - Knowledge Translation to Optimize Adherence to Evidence-Based Therapy study, a cluster-randomized trial evaluating a knowledge-translation intervention at 24 hospitals in Quebec, Canada (years: 2009 and 2012). The primary endpoint was coronary catheterization. The secondary endpoints included in-hospital mortality, percutaneous and surgical coronary revascularization, major bleeding, total stroke, and discharge prescription of evidence-based medical therapy. Results Of 3444 included patients, 2738 were White, and 706 were people of colour. The mean age was 68.2 years (33.3% women) among White patients and 69.5 years (36.0% women) among patients of colour. Patients of colour were less likely to undergo in-hospital coronary catheterization than were White patients (74.5% vs 80.3%, P = 0.001). This difference was attenuated after adjusting for patient-level characteristics (odds ratio 0.89; 95% confidence interval 0.73-1.09), and it was eliminated after adjusting for hospital-level characteristics (odds ratio 1.04; 95% confidence interval 0.73-1.49). Conclusions Racial disparity in coronary catheterization for ACS persists within a universal healthcare context. Patients’ comorbidities and hospital-level factors may be partially responsible for this inequality. Future research on cardiovascular healthcare in patients with diverse racial/ethnic backgrounds in universal healthcare systems is needed to remediate racial inequality in ACS management.
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Affiliation(s)
- Marc-André d’Entremont
- Sherbrooke University Hospital Centre (CHUS), Department of Medicine, Division of Cardiology, Sherbrooke, Quebec, Canada
- Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Christina C. Wee
- Beth Israel Deaconess Medical Centre, Department of Medicine, Division of General Medicine, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Michel Nguyen
- Sherbrooke University Hospital Centre (CHUS), Department of Medicine, Division of Cardiology, Sherbrooke, Quebec, Canada
| | - Étienne L. Couture
- Sherbrooke University Hospital Centre (CHUS), Department of Medicine, Division of Cardiology, Sherbrooke, Quebec, Canada
| | - Samuel Lemaire-Paquette
- Sherbrooke University Hospital Centre (CHUS), Department of Medicine, Division of Cardiology, Sherbrooke, Quebec, Canada
| | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Department of Medicine, Saint-Charles-Borromée, Quebec, Canada
| | - Marc Afilalo
- Jewish General Hospital, Department of Emergency Medicine, Montreal, Quebec, Canada
| | - Stéphane Rinfret
- McGill Health University Centre, Department of Medicine, Division of Cardiology, Montreal, Quebec, Canada
| | - Erick Schampaert
- Hôpital du Sacré-Cœur de Montreal, Department of Medicine, Division of Cardiology, Montreal, Quebec, Canada
| | - Samer Mansour
- Montreal University Hospital Centre (CHUM), Department of Medicine, Division of Cardiology, Montreal, Quebec, Canada
| | - Martine Montigny
- Cité-de-la-Santé, Department of Medicine, Division of Cardiology, Laval, Quebec, Canada
| | - Mark Eisenberg
- McGill Health University Centre, Department of Medicine, Division of Cardiology, Montreal, Quebec, Canada
| | - Claude Lauzon
- Centre Hospitalier Régional de l’Amiante, Department of Medicine, Thetford Mines, Quebec, Canada
| | - Jean-Pierre Déry
- Quebec Heart and Lung Institute, Department of Medicine, Division of Cardiology, Quebec City, Quebec, Canada
| | - Philippe L’Allier
- Montreal Heart Institute, Department of Medicine, Division of Cardiology, Montreal, Quebec, Canada
| | - Jean-Claude Tardif
- Montreal Heart Institute, Department of Medicine, Division of Cardiology, Montreal, Quebec, Canada
| | - Thao Huynh
- McGill Health University Centre, Department of Medicine, Division of Cardiology, Montreal, Quebec, Canada
- Corresponding author: Dr Thao Huynh, McGill University Health Centre, 1650 Ave, Cedar, Rm E-5200, Montréal, Quebec H3G 1A4, Canada. Tel.: +1-514-934-8075.
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Couture EL, Farand P, Nguyen M, Allard C, Wells GA, Mansour S, Rinfret S, Afilalo J, Eisenberg M, Montigny M, Kouz S, Afilalo M, Lauzon C, Dery JP, L'Allier P, Schampaert E, Tardif JC, Huynh T. Impact of an invasive strategy in the elderly hospitalized with acute coronary syndrome with emphasis on the nonagenarians. Catheter Cardiovasc Interv 2018; 92:E441-E448. [PMID: 30269415 DOI: 10.1002/ccd.27877] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 06/12/2018] [Accepted: 08/26/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Published data about nonagenarians with acute coronary syndrome (ACS) were mainly descriptive and limited by small sample sizes and unadjusted outcomes. We aim to describe the characteristics, management, and the impact of an invasive strategy on major adverse events in elderly patients hospitalized with ACS with focus on the nonagerians. METHODS AND RESULTS We analyzed data collected as part of the AMI-OPTIMA study, a cluster-randomized study of knowledge translation intervention versus usual care on optimal discharge medications in patients admitted with ACS at 24 Canadian hospitals. To determine whether an invasive strategy improved outcomes in the elderly, we used inverse probability weighting to adjust for confounders between patients who underwent invasive versus conservative strategies. Of 4,569 consecutive patients: 2,395 (52%) were <70 years old, 1,031 (23%) were septuagenarians, 941 (21%) were octogenarians, and 202 (4.4%) were nonagenarians. An invasive strategy was associated with reduced in-hospital all-cause mortality in all age groups: 1.1% versus 3.8% in patients <70 years old (P < 0.001), 2.9% versus 7.4% in septuagenarians (P < 0.001), 5.1% versus 14.7% in octogenarians (P < 0.001), and 12.0% versus 25.1% in nonagenarians (P = 0.001). An invasive strategy was also associated with higher thrombolysis in myocardial infarction major bleeds in the nonagenarians (9.0% vs. 2.0%; P = 0.003). CONCLUSIONS The reduction in in-hospital mortality associated with an invasive strategy in elderly and nonagenarians presented with ACS is generating hypothesis and merits further studies to confirm these benefits and to guide clinicians in the management of these high-risk patients.
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Affiliation(s)
- Etienne L Couture
- University of Ottawa Heart Institute, Ottawa (ON), Canada.,Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (QC), Canada
| | - Paul Farand
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (QC), Canada
| | - Michel Nguyen
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (QC), Canada
| | - Catherine Allard
- Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke (QC), Canada
| | - George A Wells
- University of Ottawa Heart Institute, Ottawa (ON), Canada
| | - Samer Mansour
- Centre Hospitalier Universitaire de l'Universite de Montreal, Montréal (QC), Canada
| | | | | | | | | | - Simon Kouz
- Centre Hospitalier Regional de Lanaudiere, Saint-Charles-Borromée (QC), Canada
| | - Marc Afilalo
- McGill Health University Center, Montreal (QC), Canada
| | - Claude Lauzon
- Centre Hospitalier de l'Amiante, Thedford Mines (QC), Canada
| | | | | | | | | | - Thao Huynh
- McGill Health University Center, Montreal (QC), Canada
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